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04030052CITY OF CUPERTINO �-4 + C©N'RAC�TQI�.i1VFU12MA.IUN'" BUILDING DIVISION PERMIT $rc a,f BuaDING ADDRESS: SOUTH BAY CONSTRUCTION CO x"'904030052 2370 TORRR PARKING ER'S NAME: PERMIT ISSUE DATE CTC FUNDING L NE: SANITARYNO. CONTROL NO. (408)379-0400 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION lob Description 1 Woby Mm tha,1 am liamed under provisions of Chapter 9 (commencin Sec" "7")of Divialan 3 of'be Business aM Profasions Code.and my lice s in tars and eIT t ? In. en CI L� REVISIO -IN HOUSE USE ONLY RMIT ISSUED/ORIG. #03080086 Da C motor RCNITEC'S D ATION 1 understand my plans shall W used As public records Licensed Pmfasional OWNER -BUILDER DECLARATION 1 hereby alirm that 1 am uempt form the Cenvamors License Law for the following reason. (Section 7151.5, Business and Prafesaions Code: Any city or county which mquima a permit or comment. alcor, W prove, demolish, or repair any structure prior m its issuance. also requires the applicant for such permit to file a signed statement that he is licensed random to im, provision or the CommeWle License Law (Chapter 9 Sq. Ft. Floor Area Valuation$39 (commencing with Senion 7000) of Division 3 of the Bassoon and Prefessions Code) or that he u exempt therefrom and the basis for the alleged exemption. Any Violallon of APN Number Occupancy Type Section 7031.5 by arty applicant fora permit subjects the applicant to a civil penally of not mom than five hundred dollars (5500). 36940017.00 ❑Las owner o(the property, er my employes with wegesas their sole compensation, e ns Required Inspections will de the work.and the southern is not intended or offered for sale (Sm. 7044. Business and Profession, Code: The Connector's Liccrus Lew does not apply to an owner of q P propeny who builds or imMows thereon, and who da, such work himself er through his .we employees, provided that such Imprawments ammo Intanded are@red fmsale. if, however, the building or improvement is sold within one yev of completion. Ne ewer - builder will hays the burden of praying tot he did ret build or improv for purpose of sale.). 1, As owner of Ne property, am exclusively contracting with flamed convectors in J \ construct the pmject (Sec. 7044, Business and Pmfasions Code:) The COntraelers U - come raw dos not apply to an owner of property who Wilde or improve thereon, and who comment for such pmjem with a conllecmr(s) licensed pension, to th, Consumes r7 License Law. ❑ 1 am exempt under Sa. . B @ P C (err this moron Date WORKER'S COMPENSATION DECLARATION 1 thereby affirm under penalty of perjury one of the following decimations: I haw and will mountain aCenificate of Consent to Bair -Insure for Workers Compart. sation, as previded for by Section 3700 of the Latter Code, for lie performance of the work for which this permit is issued. ❑ I haw and will maintain Workers Compensation Insurance, a required by Secdon 37W of the Labor Code. for the performance of the wark for which this permit is issued. My We Em Em tau td Policy number Are. rrier.�l-" I cy C RTIF CATECATE OF WORKERS' . COMPENSATION INSURANCE (Thu suction head not hecomplemd film, permit Is forone hundred dallan (5100) tar less.) I anify that In the pednrmenee of the work for which this permit is issued. I shall not employ say person in any manner so az in homno, subject o the Warkcrs' Courpromthim Laws of California. Dam Applicant NOTICE TO APPLICANT: If, aper making this Ceniftaue of Exemption, you should become subject m the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTIONomisacLENDINGAGENCY 1 1 hereby Affirm that Nem is m oasmeninn lending agency I'm du performan x of k for Whlc1h18 permit is lulled (SCC. 3097, LTV. C.) workll Lids Name Lender'ms Address Lm i 1 eenify Out I have read Nis application end mute that Ne show information is l correct 1 agree to comply with all city and county ordinances and state laws relating to building convection, and hereby authorive mpresenta ivrs of this city to enter upon Ne above-mentioned property for inerMLtion purposes. 1 (We) agree to raw, indemnify and keep harmless the City of Cupertino against i liabilities, judgments, case and expenses which may in any way am= against said City , 5 in conn ucncc hf the gaming of this permit. ' APP UNDERSTAN WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE ONS. Re -roofs Type of Roof store piton comm r HAZARDOUS MATERIALS DISCLOSURE Will the applicant or building or handle melriai m,future hapt r9A Health e. Chapter As dcOncd by the CupeAno Municipal Code. Chapter 9.13, and the Hcelth m0 Safety e. Seetien 25532(a)? - ❑ Yes OP All roofs shall be inspected prior to any roofing material being installed. - If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future bedding uccupam sac equipment at devims which hazardous air contami ams as defined by tiro Bay Arca Air Quality Management all new materials for inspection. ict? ❑Yee u Ini.H.-I" 1 haw mad die Ismanleus awamulsroquire came, under Chapmrb.95of the Califon Sai' ty'Codc, Secuens 255(15. 3 d255J4.l undcrstandthatifdm Wilding not torten, haw atenant that' my nsibility m nouly Ota open, of the iremenewldc e I in i c a CeniEamor tP y. Signature of Applicant Date/41. All roof coverings to be Class "B" or better Owns authan73 agent oa